Aortic valve repair of congenital bicuspid aortic valve associated with aneurysm of the ascending aorta

Two unusual cases of congenital bicuspid aortic valve associated with aneurysm of the ascending aorta are reported. One patient with a 7-cm ascending aortic dilatation and aortic regurgitation (AR) (II/IV), and another with a 6-cm ascending aorta and AR (III/IV), presented for treatment. Replacement of the ascending aorta and aortic valve repair were performed in both cases. Aortic valve repair included resection of the raphe, leaflet plication and subcommissural annuloplasty. Both patients had satisfactory results in the early postoperative period. Despite the promising outcomes after surgery in these patients, long-term changes in valve function and durability remain unknown. Additional close observation and monitoring are required before the procedure can be recommended as the standard of care.     

Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery

BACKGROUND:

Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated.

METHODS:

A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival.

RESULTS:

The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival.

CONCLUSIONS:

In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.     

Mitral valve repair with aortic valve replacement in rheumatic heart disease

From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement (p = 0.4). Survival at 9 years was 96.5 +/- 1.4% after mitral valve repair and 89.7 +/- 7.8% after mitral valve replacement (p = 0.73). Freedom from major bleeding at 9 years was 94.8 +/- 2.4% after mitral valve repair and 81 +/- 7.2% after mitral valve replacement (p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.     

Right thoracotomy for aortic valve replacement in the adolescents with bicuspid aortic valve

Background: In this study, we compared our experience about early and midterm follow‐up outcomes for right anterolateral minithoracotomy (RAMT) vs full sternot‐ omy (FS) in surgical aortic valve replacement (AVR) among adolescents with bicuspid aortic valve (BAV).
Methods: Patients were retrospectively enrolled from January 2008 to December 2017. Inclusion criteria were patients with BAV who had to undergo to AVR. They were divided in two groups: RAMT and FS. The choice of RAMT was based on indi‐ vidual surgeon’s preferences or when expressly requested by patient that was in‐ formed of nonconventional approach.
Results: We enrolled 61 patients, 23 in RAMT group and 38 in FS group. The mean age was 15.6 ± 1.7 years for RAMT group and 16.1 ± 1.5 years for FS group (P = .23). The RAMT group had a higher prevalence of female gender (P = .04). The patients in the RAMT group had longer cardiopulmonary bypass (115.2 ± 18.5 vs 102.2 ± 16.5 min; P = .006) and cross‐clamp time (78.6 ± 18.1 vs 74.3 ± 15.2 min; P = .01). No pa‐ tients required intraoperative conversion to FS. No differences were found in venti‐ lation times, postoperative intensive care unit (ICU), and hospital length of stay for both groups. Follow‐up echocardiograms were available for all patients at median of 5.2 years (range 0.5‐9.6 years, median 5.4 years for RAMT and 5.1 for FS) and no patient required reoperation for aortic prosthesis malfunction.
Conclusions: Our study shows that RAMT is safe and effective as FS. Although the RAMT operation takes slightly more operation time, it is not associated with major adverse effects.     

Aortic dimensions in patients with bicuspid aortic valve without significant valve dysfunction

The dimensions of the entire aorta at different anatomic levels were measured by transthoracic 2-dimensional echocardiography in 162 consecutive patients with isolated bicuspid aortic valves (BAVs) without significant aortic valve dysfunction. Aortic dilation involved the aortic root and the ascending aorta but was not present in the descending and abdominal aorta. A significant increase in the dimensions of the aortic arch was found in patients with BAVs aged >40 years. Ascending aortic diameter and the extension of aortic dilation were significantly correlated with age, but no correlation was found between aortic dimensions and aortic valve morphology.     

Aortic elasticity and size in bicuspid aortic valve syndrome.

AIMS: To investigate the relation between aortic elastic properties and size in bicuspid aortic valves (BAVs). METHODS AND RESULTS: 127 BAV outpatients (121 males; age 23 +/- 10 years) with no or mild valvular impairment, were recruited with 114 control subjects comparable for age, gender, and body size. Aortic distensibility (DIS) and stiffness index (SI) were derived by M-mode evaluation of the aortic root together with blood pressure measured by cuff sphygmomanometer. BAVs vs. controls had increased aortic diameter (P < 0.0001), higher systolic (P = 0.02) and pulse (P = 0.04) pressures. DIS was lower in BAVs than in controls (4.71 +/- 3.67 vs. 7.44 +/- 3.94 10(-6) cm(2)dyne(-1), respectively; P < 0.0001) and SI was greater in BAVs (7.21 +/- 4.93 vs. 3.57 +/- 1.88, respectively; P < 0.0001). Definite impairment in aortic elasticity was present in 53 (42%) BAVs. Both DIS and SI were related (P < 0.0001) to aortic size in BAVs and controls. After adjusting for aortic size and blood pressure, the regression relations between SI and aortic diameter of BAVs were significantly different from controls (P = 0.0052). CONCLUSION: Abnormal aortic elasticity is a common finding in BAVs with no or mild aortic valve impairment. However, impaired aortic stiffness is not due to aortic dilation. Simple assessment of aortic size may thus fail to identify early abnormal load bearing characteristics of the aortic wall in BAVs.     

经导管主动脉瓣置换术治疗二叶式主动脉瓣狭窄中的CT评估

目的 探讨经导管主动脉瓣置换术(TAVR)治疗二叶式主动脉瓣狭窄的临床疗效和术前评估要点.方法 纳入阜外医院2020年1月～2020年12月完成的TAVR患者54例.分析主动脉根部形态学特点、手术有效性及安全性.结果 三组瓣膜选择的oversize(测量瓣环直径/选择瓣环直径-1)为:-0.22±8.62％vs.0.5...     

Aortic pseudocoarctation associated with a stenotic congenitally bicuspid aortic valve

The diagnosis of aortic coarctation is when a high-velocity Doppler jet is seen in the proximal descending aorta. Such a jet was seen in a 23-year-old man with bicuspid aortic valve complicated by severe aortic insufficiency in the presence of a normal aorta with slight tapering confirmed by magnetic resonance imaging. After aortic replacement, the gradient was no longer seen. In conclusion, high flow in the aorta induced by large regurgitant volumes can result in the appearance of "relative stenosis" or pseudocoarctation.     

经导管主动脉瓣置换术治疗二叶式主动脉瓣畸形的研究进展

二叶式主动脉瓣(BAV)畸形是主动脉瓣畸形中较为常见的一种瓣膜发育异常.目前,经导管主动脉瓣置换术(TAVR)是治疗中、高风险BAV患者的重要方法,但一些围术期因素仍是影响患者预后的重要因素.我们通过对TAVR治疗BAV畸形的相关研究进行回顾分析,希望为提高患者的预后提供更多方法.     

Transcatheter aortic valve replacement outcomes in bicuspid compared to trileaflet aortic valves

Aim

TAVR in patients with bicuspid aortic valves (BAV) is more challenging compared to individuals with trileaflet aortic valves (TAV). BAV have been excluded from the large randomized clinical trials assessing transcatheter aortic valve replacements (TAVR) and has been considered as a relative contraindication to TAVR. To report the outcomes of TAVR in BAV and compare them to TAV in the National Inpatient Sample (NIS).

Results of valve preservation and repair for bicuspid aortic valve insufficiency

BACKGROUND AND AIM OF THE STUDY: There is increasing interest in aortic valve-sparing and repair techniques for the treatment of aortic insufficiency (AI) and/or root aneurysm. The results of bicuspid aortic valve (BAV) repair at the authors' institution were evaluated. An attempt was made to assess the mode of failure and to identify surgical methods that provide durable repair results. METHODS: Aortic valve repair for BAV was performed in 71 patients (62 men, nine women; mean age 41.5 +/- 13.2 years) between 1993 and 2005. Repair techniques included cusp free margin plication (n = 47), subcommissural annuloplasty (n = 27), free margin reinforcement (n = 10), and cusp triangular resection (n = 7). Thirteen patients had remodeling of one or both aortic sinuses, and 16 had reimplantation of the aortic valve. The ascending aorta and arch were replaced in 29 and five patients, respectively. Concomitant mitral and coronary bypass surgeries were performed in 10 and three patients, respectively. RESULTS: There were no operative deaths. Early postoperative echocardiography revealed no or trace AI in 54 patients and mild AI in 17. There was only one late death which was non-cardiac-related. Eight-year freedom from endocarditis, thromboembolism and anticoagulation-related hemorrhage was 90%, 100% and 100%, respectively. Eight-year freedom from AI grade > or =3+ (moderate) and aortic valve replacement were 44% and 82%, respectively. At the latest follow up, 89% of patients were in NYHA functional class I. Patients who underwent aortic valve-sparing procedures had more stable valve function than those who had cusp repair and subcommissural plication. CONCLUSION: BAV repair is a safe procedure with good early functional results. However, recurrent AI remains a problem at five to eight years of follow up. Since dilation of the aortic root is a common cause of AI and a common feature of patients with BAV, aortic valve-sparing reimplantation operations should provide better long-term outcomes.     

Mitral valve repair versus replacement

When considering all the major series comparing the early and late results of mitral valve repair versus prosthetic or bioprosthetic mitral valve replacement, the operative mortality rate is slightly lower for patients undergoing valve reconstruction. Late survival is also superior after valve repair. Although these modest differences may be related to patient selection bias, a lower rate of thromboembolic and endocarditis-related complications and improved LV function remain as rather compelling factors favoring valve repair. The durability of valve repair is comparable to valve replacement in terms of reoperation rate, except in cases of rheumatic valve abnormality (in which reoperation rates are higher after valvuloplasty). Definitive, objective evidence favoring mitral valve repair is lacking given the short period of followup in all studies and absence of controlled, randomized clinical trials. The success of mitral valve reconstruction relies heavily on the experience and technical expertise of the surgeon. The wide variability in observed survival rates, however, is unlikely to be due to differences in surgical skill between experienced groups; it more likely represents the results of differing criteria for mitral valve repair, various followup intervals, and comparisons between distinctly different cohorts. Although a prospective randomized trial would be ideal to compare the results of mitral valve reconstruction versus mitral valve replacement for patients with mitral valve regurgitation, it is unlikely and unrealistic that such a study will ever be conducted. The universal applicability of the results of such a study would also be dubious, given the widely varying extent of surgical expertise with mitral valve repair. Furthermore, not all types of mitral regurgitation are amendable to reconstruction short of using patch techniques (usually autologous pericardium treated with glutaraldehyde) or resorting to artificial chordae (e.g., extensive leaflet destruction from rheumatic changes or infective endocarditis, and substantial anterior leaflet redundancy). In cases in which mitral valve replacement is necessary, preservation of the mitral subvalvular apparatus promises to be an important concept to preserve optimal systolic LV function postoperatively.     

Aortic valve leaflet disruption techniques in transcatheter aortic valve replacement

With continued technological advancement and technical improvement of transcatheter aortic valve replacement (TAVR), it has become a desirable treatment option for aortic valve stenosis. Its minimally invasive approach compared to surgical aortic valve replacement offers the treatment to a broader patient population, mainly non-surgical candidates. A feared complication of TAVR is the occlusion of coronary artery ostium by the native aortic valve leaflet due to its displacement by the expanded transcatheter valve. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a technique developed to mitigate this risk by creating a lengthwise laceration of the left and/or right aortic valve leaflets prior to TAVR. Patient outcomes following TAVR with BASILICA have been promising. Meticulous preoperative examination, patient selection, and hemodynamic management are imperative. With continued refinement, BASILICA may further expand the application of TAVR to patients at high risk for coronary occlusion associated with the procedure.

Since the very first human transcatheter aortic valve replacement (TAVR) procedure in 2002, more than 200,000 TAVRs have been performed worldwide.^[1] Though it was reserved for select non-surgical candidates in the early stages of development, its application is expanding considerably in recent years. Large randomized controlled studies have compared outcomes of TAVR versus surgical aortic valve replacement (SAVR) for intermediate and high-risk patients and found no significant difference in primary outcome of morbidity from major stroke or mortality at one year and two years, respectively.^[2,3] Furthermore, a study of similar design involving low-risk patients found that TAVR patients had significantly lower rate of death, stroke, or rehospitalization at one year.^[4] Another evolving application of TAVR is to salvage a failing bioprosthetic valve, known as valve-in-valve (ViV) procedure.^[5] Minimally invasive aspect of TAVR confers a major advantage over SAVR, and the patient outcomes have been promising thus far. Despite its advantages, TAVR is associated with several notable risks. Firstly, without follow-up data from past six years, the durability of TAVR valves is uncertain. Therefore, current recommendations still favor SAVR for younger patients with longer life expectancy.^[6,7] However, one of the most consequential intraoperative complications of TAVR is the occlusion of coronary artery. With the placement of the prosthetic valve, an existing aortic valve leaflet may displace outward and directly occlude the adjacent coronary ostium or block the entire sinus of Valsalva, resulting clinically significant coronary obstruction. The left coronary ostium is much more frequently affected than the right coronary ostium, likely due to its lower height of the ostium in relation to the leaflet.^[8] Most cases of coronary obstruction manifest as severe hypotension immediately following the deployment of the prosthetic valve.^[8–10] The incidence is less than 1% in TAVR performed on native aortic valves, but it increases over 3-fold in ViV TAVR procedures.^[11,12] Majority of patients with TAVR-related coronary obstruction in the past have received emergent percutaneous coronary intervention and a much smaller number received coronary artery bypass grafting.^[8] Despite these measures, the 30-day mortality of coronary obstruction in patients undergoing ViV TAVR is reported to be 48.6%, which is likely much higher than in patients with coronary obstruction during native valve TAVR.^[8,11]Given the high rate of catastrophic outcomes associated with coronary obstruction, efforts must be devoted to preventive strategies. Several factors have been identified which include pre-existing surgical bioprosthetic aortic valve, older age, female gender, no history of coronary artery bypass grafting, and higher risk profile according to the logistic European System for Cardiac Operative Risk Evaluation (logEuroSCORE).^[10] The patient characteristics are likely significant due to the anatomic variability associated with them which include significantly smaller aortic annulus areas, sinus of Valsalva diameters, sino-tubular junction diameters, and lower left coronary artery heights as.^[10] In ViV patients, the prior surgical valve location, manipulation of the aortic root, and implantation of coronary grafts may affect these parameters considerably.^[12] With knowledge of these factors contributing to the risk of coronary obstruction, meticulous protocols are applied to stratify patient risk, as well as to plan the procedure appropriately.^[13,14]Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a novel technique developed to create a lengthwise laceration down the middle of an aortic valve leaflet from the base to the tip.^[15] The goal of this technique is to prevent coronary obstruction by creating a separation in the existing valve leaflet through which the coronary artery can remain open and perfused when the leaflet is displaced outward by the transcatheter valve and the details have been previously described.^[14,15] Briefly, this is accomplished by traversing an electrified guidewire through the mid-base of the valve leaflet of interest. The guidewire is then captured by a ring snare pre-positioned at the aortic outflow tract through a separate catheter. Then the guidewire and snare are both manipulated to position the cutting segment of the electrified guidewire in contact with the valve leaflet, which creates the valve laceration with electrocautery (Figure 1).Open in a separate windowFigure 1Schematic illustration (A) and transesophageal echocardiography (B) of mid-esophageal long axis view showing the electrocautery apparatus (arrow) in place for BASILICA.BASILICA: bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction.Initial testing of BASILICA in swine revealed successful laceration of the aortic valve leaflet without collateral injury on necropsy, except in the first trial while refining the technique.^[15] Clinical trial was subsequently performed and showed promising results.^[16] Of 30 patients, all subjects were free of coronary obstruction, despite being categorized as high risk based on preoperative evaluation.^[16] Due to the relatively small sample size, several questions remained unanswered regarding the safety of BASILICA, such as the risk of stroke and major vascular complications. However, many centers began to perform BASICILA over the recent years, including here at UC Davis Medical Center. As a result, the multicenter international BASILICA registry has accumulated data on 214 patients who underwent the procedure at 25 centers in North America and Europe.^[17] Analysis of the registry revealed that leaflet laceration was performed successfully in 94.4% of the patients and among those patients, 4.7% of patients experienced partial or complete coronary occlusion.^[17] The patients with coronary obstruction were successfully treated with coronary stents, but one patient died from cardiogenic shock despite the interventions. Considering the previously established mortality ranging between 40% and 50% in patients who experience coronary obstruction due to TAVR without BASILICA, the mortality of 10% in patients who experience coronary obstruction with BASILICA bolsters the benefits of this procedure.^[18] The authors’ explanation for this finding is that the obstruction resulting after BASILICA is not flow-limiting and the space created by BASILICA often allows placement of coronary stents through the struts of the transcatheter valve, instead of the traditional “snorkel” stent.^[17] Overall, the 30-day mortality and incidence of stroke reported through this registry were 2.8% and 2.8%, respectively.^[18] This is similar to the data of all patients undergoing TAVR reported by the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.^[18] Considering that patients who underwent BASILICA are at higher risk than the average TAVR patients, this result supports the implementation of BASILICA for this subset of patients.BASILICA requires meticulous planning and certain patient factors make the procedure less feasible. A large portion of the failed BASILICA were attributed to failure to traverse the electrified guidewire through the leaflet due to the extensive calcification. Hence, it may be a relative contraindication for the procedure. Anesthetic planning is also an important component in taking care of these hemodynamically fragile TAVR patients. This is highlighted by the authors of the BASILICA registry analysis, who attributed one of the deaths to cardiogenic shock resulting from the anesthesia induction.^[18] Although moderate sedation may be considered, there is a strong preference for general anesthesia (GA) with endotracheal intubation. In case of severe hemodynamic compromise that requires emergent surgical intervention or mechanical circulatory support, GA with a secure airway is necessary. Furthermore, transesophageal echocardiogram (TEE) can be performed much more safely with a secured airway with an endotracheal tube. Particularly in this patient population, critical intraoperative complications, such as wall motion abnormalities can be detected early using TEE to direct clinical management.